(To be filled-up by the BIR)

DLN:
BIR Form No.
Republika ng Pilipinas
Application for Tax
Kagawaran ng Pananalapi
Kawanihan ng Rentas Internas Credits / Refunds 1914
January 2001

Fill in all applicable spaces. Mark all appropriate boxes with an "X"
Part I Background Information
1 Taxpayer 1 2 Home RDO Code 2
Identification No.
3 Taxpayer's Name 3

4 Registered 4A
Address
4A

Zip Code 4B Telephone Number 4C

Part II Details of Tax Credits/Refunds

5 Tax Type 5

6 Period Covered From To

(MM/ DD/ YYYY) 6A 6B
7 Mode of Claim 7A Tax Refund 7B Tax Credit Certificate

8 Claim Amount 8

Part III Reason for Filing

9 Reason for Filing the Claim
9A Refunds or Tax Credits of Input Tax 9E Expired TRN (Reissuance)
9B Claim Arising from Special Laws / Tax Treaties 9F Overpayment
9C Claim Arising from Erroneous Payment of Taxes 9G Regular Excise Claims
9D Lost TRN (Replacement) 9H Others (please specify)

Part IV Legal Provision

10 Legal Basis 10

I declare, under the penalties of perjury, that this application has been made in good faith, Stamp of Receiving Office
verified by me and to the best of my knowledge and belief, is true and correct, and that no and Date of Receipt
refund or tax credit involving the same tax has previously been claimed or received.

11 TAXPAYER'S SIGNATURE OVER PRINTED NAME 12 POSITION/TITLE